The nurse assesses a patient who had a total abdominal hysterectomy 2 days ago. Which information about the patient is most important to communicate to the health care provider?
The 24-hour oral intake is 600 ml greater than the total output.
The patient's temperature is 100.3" F 137.9" C).
The patient reports abdominal pain at level 6 (0 to 10 scale) when ambulating
The patient's calf is swollen, warm, and painful.
The Correct Answer is D
These symptoms suggest the possibility of deep vein thrombosis (DVT), which is a potentially serious complication following surgery. DVT occurs when a blood clot forms in a deep vein, commonly in the lower extremities. The symptoms of a swollen, warm, and painful calf can indicate the presence of a DVT.
DVT is a medical emergency that requires immediate attention and intervention to prevent further complications such as a pulmonary embolism (where the blood clot travels to the lungs). Prompt evaluation and treatment, such as anticoagulant therapy, are necessary to prevent complications
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A 3% saline solution is a hypertonic solution used to increase serum sodium levels in cases of severe hyponatremia. However, it can lead to fluid overload and pulmonary edema. The presence of crackles throughout both lung fields indicates the accumulation of fluid in the lungs, which is a serious adverse outcome.
The patient's radial pulse rate of 105 beats/min is within a normal range and does not directly indicate an adverse effect of the saline infusion.
The presence of sediment and blood in the patient's urine may be unrelated to the 3% saline infusion and could indicate other issues such as urinary tract infection or kidney injury.
An increase in blood pressure from 66/50 to 122/74 mmHg is an expected effect of a hypertonic solution like 3% saline, as it can cause an increase in intravascular volume. While the increase in blood pressure is significant, it does not represent an adverse outcome specific to the infusion itself.
Correct Answer is C
Explanation
Taking an extra dose of Aspirin prior to surgery can significantly increase the risk of bleeding during and after the surgical procedure. Aspirin is a non-steroidal anti-inflammatory drug (NSAID) that can interfere with the normal blood clotting process. Surgical procedures often require meticulous control of bleeding, and the presence of Aspirin in the patient's system can pose a significant risk.
It is essential for patients to follow preoperative instructions provided by the healthcare team, including avoiding certain medications or substances that can increase the risk of complications during surgery. Taking an extra dose of Aspirin, especially without consulting the healthcare provider, can jeopardize the safety of the surgical procedure and may require rescheduling to ensure the patient's well-being.
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